Title: Clinical Decision Making in Telehealth. An intuition or analytical process?
Abstract:
The ever changing landscape of healthcare worldwide and the rapid growth of new technologies, along with changes to government policy has led to the growth in the delivery of healthcare using these technologies. This Professional Doctorate aimed uniquely to explore how clinical decisions were made by nurses working in a national Telehealth organisation in Scotland and whether it was an intuitive or analytical process? A two stage mixed methods design was used to explore these research questions.
Phase one involved the review of management information routinely collected by the organisation of 25 000 calls from the public. Phase two explored nurses’ perceptions of how they make clinical decisions in focus groups and interviews (n=18). A dual process theory of clinical decision making was used as the conceptual framework for the study.
Findings from Phase one indicate in a randomly selected week, nurses used decision making tools, in the form of algorithms in only a fifth (n= 5692/25 620) of the calls, and that the highest percentage 14.8% (n= 843/5692) of algorithms were used in calls involving children’s’ health. Phase two findings identified five themes which explained how nurses made safe appropriate decisions in this setting. These were listening to the patient’s story to build a picture, journeying from algorithm use to holistic care, battling with the workload, seeing red in Telehealth Nursing and the movement from novice to expert in Telehealth. These themes explained how nurses used active listening and skilled questioning, guided by the use of an algorithm or their own experience to develop a picture of the patient’s presenting symptoms in their ‘mind’s eye’. In addition, that this process was influenced by the nurse’s perception of the pressure on the service at the time of the call and their length of experience and confidence in their own ability to manage the call.
Findings from this first study of nurses’ decision making in this setting suggested that this process was predominantly an analytical/System 2 process. Tailoring their education and the organisation of the service to take account of the complex decision making and risk management skills will enhance the patients’ journey through the service.
